Ketoacidosis
[[Wikipedia:Ketone bodies|'Ketones']] in the urine or blood, as detected by urine testing stix or a blood ketone testing meterBlood Ketone Testing Meter--Abbott's Precision Xtra, may indicate the beginning of diabetic ketoacidosis (DKA), a dangerous and often quickly fatal condition caused by low insulin levelsKetones Increase With Lack of Insulin-Children With Diabetes combined with certain other systemic stresses. DKA can be fixed if caught quickly. Because of the hyperglycemia Cushing's disease creates, it's possible (but not frequent) to find ketones in the urinepages 7-16 Persistent Hyperglycemia in Dogs and Cats-Standards of Care-Schermerhorn-page 11. The three ketone bodies are acetone, acetoacetic acid, and beta-hydroxybutyric acid, with the predominating ketone body formed being beta-hydroxybutyrate acidPatient.co.uk-Ketones. Though they are referred to as "bodies" this is a misnomer as they are dissolved substancesWikipedia-Ketone Body. Ketones are produced by the liver as part of fat metabolism and are normally not found in sufficient quantity to be able to be measured in urine or blood (non-diabetics or well-controlled diabetics)Diabetes mellitus CVC Proceedings 2009-DVM 360. Since the body is set up to normally burn glucose as its fuel, when glucose isn't available as an energy source, (untreated/poorly treated diabetes and some other unrelated medical conditions), it begins to burn fat for energy instead. The result of the body turning to burning fat instead of glucose means more ketone production which is able to be measured when testing either urine or blood for themPatient.co.uk-Ketones. Emergency Info Diabetics of all species therefore need to be checked for ketones with urine testing stix, available at any pharmacy, whenever insulin level may be too low, and any of the following signs or triggers are present: Note that the triggers and signs are somewhat interchangeable because ketoacidosis is, once begun, a set of vicious circles which will make itself worse. So dehydration, hyperglycemia, fasting, and presence of ketones are not only signs, they're also sometimes triggers. How to check When testing urine for ketones, the sample needs to be as fresh as possible. Ketones evaporate quickly, so there's a chance of getting a false negative test result if you're testing older urineUrinalysis Dipstick Interpretations-University of Georgia-Ketones. The stixKetone Strips-Diabetes Self-Management bottle has instructions and color charts to show you how the color on the stix will change given the level of ketones/glucose in the urine over 15 (ketones-Ketostix) or 30 (glucose-Ketodiastix) seconds. Be sure to read the colors at those time intervals because the colors will continue to darken and a later reading will be an incorrect result. Timing with a clock or watch second hand instead of counting is said to be more accurateKetone Testing-Barbara Davis Center for Diabetes. The Bayer-made, ReliOn branded ketone urine test strips sold by Wal-Mart and Sam's Club have the same instructions and color key as the Bayer brand, Ketostix.ReliOn Ketone Urine Test Strips Instructions It's important to time the test accurately and not take into account any color changes on the Ketostix strip which occur after 15 secondsMeasuring Ketones in Urine-Children With Diabetes. At low levels, ketones can be detected in the urine (ketonuria) before they are found in the blood (ketonemia/ketonaemia)BMJ Student Archive-Glycosuria and Ketonuria. Most urine tests for ketones measure acetoacetic acid, not the most common beta-hydroxybutyrate acidPatient.co.uk-Ketones. False Testing Results-Urine Ketones If your pet is taking any type of vitamin supplements, it should be noted on his or her medical records. Knowing that he/she is using them means being able to factor them into interpretations of test results. When to come to the vet thumb|300px|right|Overview of type 1 diabetes-how it's treated; how ketoacidosis begins and its treatment. Trace urinary ketones may or may not be an emergency, depending on the case. If a vet is unavailable, look for some of the other signs or triggers, and try to remedy any you can. Give extra water and food, by syringe if necessary. If it's nearly time for an insulin shot, give one. Continue testing and call a vet when possible. DKA cannot be treated at home. Veterinary care for DKA involves intravenous (IV) fluids to counter dehydrationDiabetes Mellitus-CVC Proceedings-Fluids-DVM 360 2009 and flush the animal's system of the ketonesEndocrine Emergencies-DVM 360 and when necessary, to replace depleted electrolytesPet Education.com-Drs. Foster & Smith-Potassium Requirements & DeficienciesPet Education.com-Drs. Foster & Smith-Sodium & Chloride Requirements & DeficienciesRxEd.org-Hypokalemia-Low Blood PotassiumDiabetes Mellitus in Dogs and Cats NAVC January 2008, such as bicarbonateMedicineNet-What Are Electrolytes?; intravenous or intramuscularCanine Diabetes Mellitus-Insulin Therapy-WSAVA 2009 fast-acting insulin to bring the blood glucose levels downCritical Care Monitoring Considerations for the Diabetic Patient-Clinical Techniques in Small Animal Practice-2002Low-dose Intramuscular Insulin Therapy for Diabetic Ketoacidosis in Dogs-Journal of the American Veterinary Medical Association-1981; measured amounts of glucose or force feeding, sometimes by feeding tube, to force the metabolism back from fat-burning to glucose-burning. Many times, the polyuria of hyperglycemia and ketosis means too much potassium leaves the system via the too-frequent urination, so it's possible for the body to be low on potassium because of it. However, insulin's other use besides controlling blood glucose, is when a patient has too much potassium, or hyperkalemiaInChem-Insulin. What happens then is we have someone whose potassium levels are low from too much urination and who must have insulin to manage blood glucose levels, with the knowledge that the use of the needed insulin will further deplete the potassium in the system.Diabetes Mellitus-CVC Proceedings-Electrolytes-DVM 360 2009. Many doctors opt to use Ringer's with additional potassium to bring the body back into balanceWashington State University School of Veterinary Medicine-Fluid Therapy. Dehydration becomes involved with ketoacidosis, which can mean that subcutaneous insulin injections are not properly absorbed; when this occurs, intravenous treatment with soluble, short-acting insulin is neededAmerican College of Emergency Physicians-Pediatric Endocrine Emergency Answer Sheet,along with rehydrating intravenous fluidsMerck Veterinary Manual-Diabetes Mellitus-Ketoacidosis. Dr. Michael Herrtage describes the situation well in his WSAVA presentation, "In diabetic ketoacidosis, there are serious derangements in fluid, electrolyte and acid-base statusCanine Diabetes Mellitus-Diagnosis-WSAVA 2009." Veterinary care for DKA may involve a hospital stay of five days or more and cost, in the U.S., $2,000 or more. Some animals are DKA prone, and may have multiple episodes of the condition. Veterinarians have sometimes been known to send pets home from a DKA episode while still displaying ketones in the urine due to owner financial constraints -- this can turn into a fatal mistake. Your chances of fixing the problem yourself are slim. If your cat or dog comes back from the hospital and still has ketones showing on urine testing stix, it's usually best to find the financial means to go right back to the vet's as your pet may need to stay in hospital longer. How it happens Our bodies normally are "fueled" by burning glucose; they are able to do this provided they have enough insulin (normally or by injection). When there's not enough insulin to allow the body to burn glucose for energy, it begins metabolizing fat to fuel its cells. In particular, the brain cannot go without energy even for a second, so it demands fat conversion to ketones when glucose energy is unavailableEnergy Metabolism Explained. Continuing this process using fat and ketones instead of glucose without sufficient insulin intervention is the path to ketoacidosis. Adapted from the Wikipedia: Normally, ketone bodies are produced in minuscule quantities, feeding only part of the energy needs of the heart and brain. When insulin is inadequate, fat must be turned into ketones for energy instead, and they rapidly become a major component of the brain's fuel. As a result, the bloodstream is filled with an increasing amount of glucose that it cannot use (as the body continues adding glucose to the blood with gluconeogenesis and perhaps also glycogenolysis). This extra glucose significantly increases its osmolality. At the same time, massive amounts of ketone bodies are produced, which in addition to increasing the osmolal load of the blood, are acidic. As a result, the pH of the blood begins to change. The trace element balance of the system is altered by falling bicarbonate blood levels and rising serum potassium levels. The potassium level of the body as a whole is reduced by the polyuria of ketoacidosisEndocrinology-NBCI Bookshelf- KetoacidosisProviding Care for Diabetic Veterinary Patients-IJPC-2000-Page 2. There can be changes in breathing (deep, sighing breaths) because the ketones themselves are acids. Any type of acidosis can affect the respiratory system. Glucose begins to spill into the urine as the proteins responsible for reclaiming it from urine reach maximum capacity. As it does so, it takes a great deal of body water with it, resulting in dehydrationWashington State University: Fluid Therapy in Diabetes Mellitus. The over-frequent urination takes vital minerals such as salt and potassium with it. These are known as electrolytesHow Stuff Works-Electrolytes and the right balance of them controls many automatic body functions, such as heartbeat, etcDiabetes Self Management-DKAMedicineNet-What Are Electrolytes?. Dehydration worsens the increased osmolality of the blood, and forces water out of cells and into the bloodstream in order to keep vital organs perfused. The vicious cycle is now set, and if untreated will lead to coma and deathDiabetes Mellitus-CVC Proceedings-Pathophysiology of Type I Diabetes in Dogs-DVM 360-2009. How likely is it? Since diabetic dogs are considered insulin-dependent--unable to naturally provide any of their own insulin needs once diagnosed with diabetes--they are prone to ketoacidosisBetter Medicine-E-Newsletter-June 2006. About 40% of newly-diagnosed canine diabetics have some amount of ketones when they are brought to the vetBeyond Insulin Therapy: Achieving Optimal Control in Diabetic Dogs Drs. Fleeman & Rand-U-Queensland--2005. Ketones occur quickly in younger animalsUrinalysis Dipstick Interpretation-University of Georgia-Ketones. Testing for ketones-blood and urine The usual method of testing for ketones is with urine testing stix, available at any pharmacy. When testing urine for ketones, the sample needs to be as fresh as possible. Ketones evaporate quickly, so there's a chance of getting a false negative test result if you're testing older urineUrinalysis Dipstick Interpretations-University of Georgia-Ketones. At low levels, ketones can be detected in the urine (ketonuria) before they are found in the blood (ketonemia/ketonaemia)BMJ Student Archive-Glycosuria and Ketonuria. At present there is only one device for consumers who wish to test blood instead of urine for ketones--Abbott's Precision Xtra Abbott's Precision Xtraglucometer. The meter is known by the brand name Precision/Optimum/Xceed outside of the USAbbott's Precision/Optimum/XceedAbbott Optimum Xceed. The premise behind blood testing for ketones is the same as that for favoring glucose testing of blood over urinePoint of Care Test Identifies Diabetic Ketoacidosis at Triage-Academic Emergency Medicine-June 2006Exploring the Clinical Utility of Blood Ketone Levels in ER Department Assessment of Pediatric Patients-Emergency Medicine Journal-October 2006Ketone Testing-Peter Chase-Barbara Davis Center for Diabetes. The urine ketone measurement, like urine glucose measurement, can be hours old; testing blood for both gives current values as of testing time Value of Testing Blood for Ketones Over Testing Urine-Children With DiabetesEvaluation of an Electrochemical Sensor for Measuring Blood Ketones-Diabetes Care 2000Accuracy of an Electrochemical Sensor for Measuring Capillary Blood Ketones by Fingerstick Samples During Metabolic Deterioration After Continuous Subcutaneous Insulin Infusion Interruption in Type 1 Diabetic Patient--Diabetes Care 2003Accuracy of Serum β-Hydroxybutyrate Measurements for the Diagnosis of Diabetic Ketoacidosis in 116 Dogs-Journal of Veterinary Internal Medicine 2002. Testing blood for ketones also means there are less medications and other things like lipids which can interfere with the accuracy of the testMeasuring Ketones in Blood-Children With Diabetes. Children with Diabetes Meter Which Tests Blood for Ketones-Precision Xtra advises every family with a child with diabetes should have this type of meter because of its blood ketone testing ability. The ketone test strips are about $30 for 10 individually-wrapped strips. The Precision Xtra also does blood glucose testing with standard blood glucose test strips made for use with the meter. Most urine tests for ketones measure acetoacetic acid, which is 20% of the ketones producedKetone Bodies-NDI Foundation not the most common beta-hydroxybutyrate acidPatient.co.uk-Ketones. Blood testing for ketones measures beta-hydroxybutyrate acidKetone Testing-page 33, which is 76% of the ketones producedKetone Bodies-NDI Foundation. Testing blood for ketones would provide a more accurate picture of the problem at the moment, similar to the comparison between blood testing for glucose vs urine testing. Good BG Readings but Positive Ketone Results When the bg readings are high enough to produce some ketones, you've taken action to bring them down and they are normal once more, it is possible to still see some positive urine ketone test results. Ketones show up in the urine right away. When you're getting normal bg readings, it means that there are no more ketones being produced. What you are seeing when you test urine for ketones and the blood glucose is in normal ranges are the "leftovers" of the ketones which were produced by the high bg episode. They will continue to show up in the urine for a while but their concentration will become less and less until they're goneInsulin Dependent Diabetes in Children, Adolescents and Adults-Dr. Ragnar Hanas-Page 11--Important-KetonesUrine Ketones Decrease Slowly-Children With DiabetesDiabetesNet-Ketone Detection. References More Information *Surviving diabetic Ketoacidosis-North American Veterinary Conference-2006 * [http://www.uchsc.edu/misc/diabetes/books/ud11/ud05.pdf A chapter about ketone testing from the tenth edition of Understanding Diabetes by H. Peter Chase, MD, a book about living with insulin-dependent diabetic humans] *Wikipedia:Diabetic Ketoacidosis *Treating the Complicated Diabetic Patient--Dr. David Church--WSAVA 2001 *Understanding Diabetic Ketoacidosis--WSAVA 2005 *Emergency veterinary hospitals worldwide *Metabolic Changes in Diabetic Ketoacidosis--The Genetic Landscape of Diabetes *Diabetes Now UK-Ketones Written for people but contains a lot of good information applicable to diabetes in pets also. *LabTests Online-Blood Ketones *Southpaws Newsletter-Diabetic Ketoacidosis-A Medical Emergency *Fluid and electrolyte therapy in endocrine disorders: diabetes mellitus and hypoadrenocorticism Veterinary Clinics of North America 2008 *Urine Ketone Test Information-Multistix-Cornell University *New Insights into the Management of Diabetic Ketoacidosis-WSAVA 2009 *Diabetic Ketoacidosis-Church-WSAVA 2009 *Acid-Base Abnormalities in Dogs with Diabetic Ketoacidosis: A Prospective Study of 60 Cases-WSAVA 2009 *Diabetic crises: Recognition and management (Proceedings) DVM 360-April 2008 *Endocrine emergencies (Proceedings) DVM 360 October 2008 Category:Conditions Category:Emergencies Category:Complications Category:Vicious circles Category:Terms Category:Content